Conservatives deal with facts and reach conclusions; liberals have conclusions and sell them as facts.

Liberals laugh at business — even when they concede that it functions better than government

Last night, I went to hear Atul Gawande give a talk promoting his new book, The Checklist Manifesto: How to Get Things Right. The book’s premise is a simple one: In an increasingly complex world, even experts benefit from a routine checklist that requires them to focus on the essentials necessary to their task. The best checklists are not too detailed, and leave room for individual or team autonomy. Gawande, a surgeon, came up with the idea when the World Health Organization asked him to investigate how to decrease unnecessary deaths associated with surgery. After investigating similar complex situations (building tall buildings or airplanes), Gawande concluded that checklists that force people to remember what should be obvious (but nevertheless gets forgotten or overlooked), and that enable teams actually to function as teams, were the way to go. Boeing was a huge inspiration for this.

I came away from the talk convinced that Gawande has a point (perhaps because I’m a checklist and outline person myself). I was also impressed much less favorably by his devotion to the notion of government controlled health care (he’s all for the Frankenstein monstrosity wending its way through Congress). Aside from my own prejudices, his manifest delight in the health care bill made no sense as he told anecdote after anecdote demonstrating that it’s the business sector, not the government, that is best able to adapt to his recommendations. This became most clear when he talked about Hurricane Katrina.

Gawande noted that, in the wake of Hurricane Katrina, FEMA descended on New Orleans with the Checklists from Hell. They were overly detailed, denied any personal responsibility, and prevented FEMA employees from adapting to the situation on the ground. These government generated checklists, rather than heightening efficiency, rendered government employees ineffectual.

Gawande paused after this description. Around me, all the people in this liberal, elite San Francisco audience nodded their heads wisely. “That dumb Bush and his corrupt administration,” you could practically see them thinking.

By contrast, said Gawande, you could see the effective use of checklists from . . . long pause . . . “Wal-Mart, of all things.” He paused for the obvious laugh line, and the audience obliged. What a joke that the fascist Wal-Mart commercial dictatorship would function better than government. Gawande clearly agreed, yet he went on to describe a Walmart behaving efficiently and humanely during the disaster.

Because its checklists weren’t rigid or overly long, Wal-Mart employees had a certain degree of latitude in the face of an enormous crisis. Ultimately, Wal-Mart asked only that the managers check in with headquarters daily so that they could pool information and exchange ideas. Within one day, while FEMA was still turning away supplies because they weren’t on a given employee’s checklist, Wal-Mart had arranged for free medicine to be handed out to be people who were dependent on their medicine (diabetics, for example). They were also providing essential supplies to FEMA, which was incapable of accessing its own resources.

What neither Gawande nor the audience seemed to comprehend was that this outcome wasn’t surprising, it was obvious. Government is a bureaucratic entity ultimately responsible only for more government. It is driven by fear, not by outcome. The fear each employee has that he or she might get downgraded on the civil service list, the collective entity’s fear of a funding cut, its leadership’s fear that each member will fail to ascend in the government ranks, and so on. It has no responsibility beyond its own bureaucratic survival. If it goes through the motions, and sort of gets the job done, it will continue to exist.

Business, however, must be infinitely adaptable in the Darwinian world of the marketplace. It cannot afford complacency or rigidity. It cannot afford the risk of litigation for failure. It can react with incredible speed, since management doesn’t have to go through a bureaucratic or legislative process in order to change a checklist or procedure. If Gawande really believes in his lists, the last thing he’ll want is for them to be government controlled, because they will never improve. Instead, they will stagnate in bureaucratic limbo, good enough, but never better.

Gawande’s talk left me more certain than ever that, while our health care system needs reform, handing the details over to the government is a sure recipe for a FEMA-level disaster.

Share this:

Book! I saw Gawande last week in New Haven (would gladly trade places with you in Marin as New Haven’s charms are, er, rather subtle). He opened with a long, dramatic narrative about resuscitating a drowned girl, then covered the topics in your first paragraph. A fine writer, excellent speaker, intelligent and commonsensical. And yet… Nary a word about Katrina or Fema, though. Interesting omissi0n on his part: first, that he apparently varies his patter by location (boredom?); second, Yale’s school colors are not the only thing that is blue. He did go into great detail about the current health care situation, describing how physicians have catalogued over 13,600 bodily problems, symptoms, diseases, etc., and some 6000 drugs to treat some of those problems; out of which the average doctor is familar with 300-500 symptomatic issues and has a working knowledge of 300-400 drugs. Gawande’s basic point was that we suffer from failures of execution rather than ignorance, hence the need for checklists in a complex world. Gawande further decried the “gotcha” culture of politics and health care reform — he described it as a vicious circle of a loss of trust in elites. Experts need room to fail, but are afraid to admit it, so their denial of manifest failures retards progress in learning and destroys public confidence. Book, you make the brilliant connection that escaped Gawande. In your words, “If Gawande really believes in his lists, the last thing he’ll want is for them to be government controlled, because they will never improve. Instead, they will stagnate in bureaucratic limbo, good enough, but never better.” In his New Haven talk, he seemed to imply the opposite: he lauded the progress of countries with nationalized health care that have adopted his checklists — France, for example, with an 80% adoption rate. Government is a game of cya and blame, conducted with the benefit of perfect hindsight. Lists will only grow longers, more elaborate, and useless. Ladies and Gentlemen, I give you the TSA!

Dr. Gawande’s activism in the Democratic Party predates his M.D. He was involved with the Hillarycare movement, so he has a significant personal investment in seeing some sort of government-run medical care program instituted.
While I presume he is sincere, this series of lectures that he’s been giving indicates that’s at least he’s been doing some thinking on efficiencies. I don’t know if there was any Q&A after the talks, but something like, “Your comparison of FEMA v. WalMart in their flexibility is exactly what a free-market economist would predict, and should not be too surprising. It is also at odds with what a more government-oriented economist would predict. The free-market economist would go on to comment about the tendency of any government checklist to both grow in length over time and to be treated more inflexibly over time. In light of these predictions and your research which supports the free-market position, to what extent have you re-evaluated increased government intervention in health care?” Or words to that effect.

http://photoncourier.blogspot.com David Foster

More than 30 years ago, Peter Drucker observed that “any government which is *not* a government of paper forms rapidly degenerates into a mutual looting society.”

Precisely because government has so much inherent power, it must be constrained in ways that private organizations need not be and should not be. This doesn’t mean that citizens and officials should cease to struggle against bureaucracy–some agencies work much better than others (my state DMV is remarkably good), and incremental improvements are always possible…but the idea that government can be nimble and highly-efficient, while avoiding the dangers of corruption and bureaucracy, is a chimera.

http://photoncourier.blogspot.com David Foster

(sigh)..I *meant to say: the idea that government can be nimble and highly-efficient, while avoiding the dangers of corruption and autocracy, is a chimera.

Danny Lemieux

David Foster, you write “More than 30 years ago, Peter Drucker observed that “any government which is *not* a government of paper forms rapidly degenerates into a mutual looting society.”
Uh…I think that we are there.

http://ymarsakar.wordpress.com/ Ymarsakar

The Left is a business. Except their product is slavery, not justice.

gpc31

Slightly off topic, but I’m reading Henry Hazlitt’s book “Economics in One Lesson”. (You can easily google a free pdf copy on the internet.) Marvelously lucid in only 200 odd pages. I’m tired of pretending that I know anything about economics — time to rebuild the foundation.

Mike Devx

gpc31 #8:
> I’m tired of pretending that I know anything about economics — time to rebuild the foundation.

Economics is quite easy these days, gpc.

Step 1: Spend enough money to control enough members of Congress to keep them in your hip pocket.

Step 2: Those Congresscritters will take money from everyone else in America EXCEPT YOU.

Step 3: Those Congresscritters will pass laws that favor you, and direct that money that they’ve taken from other Americans towards YOU.

How could you possibly lose?

I’ll add, parenthetically, that the government sector has grown, while the private sector has shrunk. And government employees earn on the average more than private now. Therefore, they are locked in to support the ever larger government sector, which relies on your taxes to pay them. If you believe as I do that the government sector is inherently inefficient because no one has a vested interest in making things work, and in improving, then it’s clear where this ends up. We’ll never be as badly off as Haiti, but as the years pass, the quality of life of all Americans just keeps on slowly declining, drip drip drip… every year the world a little grayer, every year things slowly grind more and more to a halt. Like losing your hair or growing older, there’s no one day that tells the story, but one morning you wake up and look in the mirror and say, “My God! What happened? How did this happen? How did we GET here?” Voters in Massachusetts may be experiencing that “morning in the mirror” moment right now.

http://photoncourier.blogspot.com David Foster

“government employees earn on the average more than private now. Therefore, they are locked in to support the ever larger government sector”…true, but it’s not just government employees per se. There are many high-paid individuals who benefit strongly from expanded government even though they are not formally government employees. See my post Paying Higher Taxes Can Be Very Profitable: http://photoncourier.blogspot.com/2010_01_01_photoncourier_archive.html#4394955345069278791

http://ymarsakar.wordpress.com/ Ymarsakar

It’s a good way to argue. If people are bitter and upset about highly paid corporate execs, it helps to funnel some of it towards a deserving target. Instead of allowing politicians to use people’s insecurity vis a vis corporate big wigs, we can use the people’s perceived self-interests against the politicians themselves and their bureaucratic support system.

Writing this blog is a labor of love. However, if you'd like to donate money for my efforts, please feel free to do so: